Haemostasis in oral surgical procedures involving patients with a ventricular assist device.

The purpose of this study was to determine whether tooth extraction for patients with ventricular assist devices (VADs) could be performed without interruption of anticoagulant and/or antiplatelet therapy and whether treatment with von Willebrand factor concentrates and desmopressin is required. The study consisted of three groups of patients undergoing oral surgery. The two experimental groups comprised patients with VADs, while the third group included cardiovascular patients without VADs who served as controls. All patients were treated intraoperatively with topical haemostatic agents (oxidized cellulose or collagen). The first group was additionally treated with fibrin glue. All 75 oral surgical procedures were performed under local anaesthesia without sedation. Three of 40 patients in the experimental groups and two of 20 patients in the control group suffered a haemorrhage, with no significant difference in the incidence of haemorrhage between the groups. The findings suggest that dental extraction can be performed without modification of oral anticoagulation or antiplatelet treatments, providing that INR is less than 3.5 on the day of the operation. It can further be hypothesized that an acquired coagulopathy in VAD patients does not influence the bleeding risk in dental extractions, and so the administration of desmopressin and/or von Willebrand factor concentrates is not required.

Candidate Genes for Nonsyndromic Cleft Palate Detected by Exome Sequencing.

Nonsyndromic cleft palate only (nsCPO) is a facial malformation that has a livebirth prevalence of 1 in 2,500. Research suggests that the etiology of nsCPO is multifactorial, with a clear genetic component. To date, genome-wide association studies have identified only 1 conclusive common variant for nsCPO, that is, a missense variant in the gene grainyhead-like-3 ( GRHL3). Thus, the underlying genetic causes of nsCPO remain largely unknown. The present study aimed at identifying rare variants that might contribute to nsCPO risk, via whole-exome sequencing (WES), in multiply affected Central European nsCPO pedigrees. WES was performed in 2 affected first-degree relatives from each family. Variants shared between both individuals were analyzed for their potential deleterious nature and a low frequency in the general population. Genes carrying promising variants were annotated for 1) reported associations with facial development, 2) multiple occurrence of variants, and 3) expression in mouse embryonic palatal shelves. This strategy resulted in the identification of a set of 26 candidate genes that were resequenced in 132 independent nsCPO cases and 623 independent controls of 2 different ethnicities, using molecular inversion probes. No rare loss-of-function mutation was identified in either WES or resequencing step. However, we identified 2 or more missense variants predicted to be deleterious in each of 3 genes ( ACACB, PTPRS, MIB1) in individuals from independent families. In addition, the analyses identified a novel variant in GRHL3 in 1 patient and a variant in CREBBP in 2 siblings. Both genes underlie different syndromic forms of CPO. A plausible hypothesis is that the apparently nonsyndromic clefts in these 3 patients might represent hypomorphic forms of the respective syndromes. In summary, the present study identified rare variants that might contribute to nsCPO risk and suggests candidate genes for further investigation.

Strong association of variants around FOXE1 and orofacial clefting.

Nonsyndromic orofacial clefting (nsOFC) is a common, complex congenital disorder. The most frequent forms are nonsyndromic cleft lip with or without cleft palate (nsCL/P) and nonsyndromic cleft palate only (nsCPO). Although they are generally considered distinct entities, a recent study has implicated a region around the FOXE1 gene in both nsCL/P and nsCPO. To investigate this hypothesis, we analyzed the 2 most strongly associated markers (rs3758249 and rs4460498) in 2 independent samples of differing ethnicities: Central European (949 nsCL/P cases, 155 nsCPO cases, 1163 controls) and Mayan Mesoamerican (156 nsCL/P cases, 10 nsCPO cases, 338 controls). While highly significant associations for both single-nucleotide polymorphisms were obtained in nsCL/P (rs4460498: p Europe = 6.50 × 10(-06), p Mayan = .0151; rs3758249: p Europe = 2.41 × 10(-05), p Mayan = .0299), no association was found in nsCPO (p > .05). Genotyping of rs4460498 in 472 independent European trios revealed significant associations for nsCL/P (p = .016) and nsCPO (p = .043). A meta-analysis of all data revealed a genomewide significant result for nsCL/P (p = 1.31 × 10(-08)), which became more significant when nsCPO cases were added (p nsOFC = 1.56 × 10(-09)). These results strongly support the FOXE1 locus as a risk factor for nsOFC. With the data of the initial study, there is now considerable evidence that this locus is the first conclusive risk factor shared between nsCL/P and nsCPO.

Columellar flap for secondary cleft rhinoplasty with esthetic improvement of Millard's unilateral cheiloplasty scar.

INTRODUCTION: Columellar cartilage graft helps improve esthetic results in secondary cleft rhinoplasty for patients presenting with cleft lips. However, inadequate skin coverage of the cartilaginous graft can result in columellar necrosis and graft loss. Moreover, the scar after Millard's primary cheiloplasty may not be esthetic. The aim of this article was to present the columellar flap technique to cover the columellar graft and to improve the scar after unilateral Millard's cheiloplasty. TECHNICAL NOTE: The triangular flap is drawn on the edge of Millard's cheiloplasty scar. It is then moved in a V-Y fashion so as to cover the cartilaginous graft and improve the esthetic aspect of the new columella. DISCUSSION: Four hundred and twelve teenage/adult rhinoplasties were performed in our department over 10 years (October 2001 to October 2011). This flap was used in 10 patients who were followed-up for at least 1 year. There were no severe postoperative complications. Millard's unilateral cheiloplasty scar was less visible. A prospective study is ongoing.

Fibular flap for mandibular reconstruction: are there old tricks for an old dog?

Fibular free flap is considered as an "old dog" in reconstructive surgery because it was first described by Taylor and his colleagues in 1975, and was then introduced for mandibular reconstruction by Hidalgo in 1989. There are some "tricks" for fibular free flap that have been used and recognized in many European maxillofacial surgical units over the past decade. These include: 1) harvesting the distal fibula when recipient vessels are distant; 2) flap selection based on the anatomy of perforators; 3) use of the skin paddle for postoperative flap monitoring; 4) protection of the flap's soft-tissue cuff; 5) preventing venous thrombosis which is essential to reduce flap complications; 6) aligning fibular struts and protecting the vascular pedicle when the double-barrel technique is used; 7) minimizing the gap between the double-barrel struts and implementing a long-term follow-up of dental implants; 8) selecting osteosynthesis materials; and 9) learning curve and clinical competence in microvascular reconstruction. We also reviewed current data from the literature, which would be useful for maxillofacial reconstructive surgeons. With these tricks, one can teach an "old dog" "old tricks".

Transient finite element analysis of a traumatic fracture of the zygomatic bone caused by a head collision.

Midfacial fractures rank first concerning maxillofacial traumatology. Collisions of two heads or head to object are the main causes for these fractures. An investigation based on a transient simulation using the finite element method was performed. A biomechanical head model was created and tested. A transient collision of two heads was simulated. The results were compared to a typical real patient case. This comparison revealed an identical fracture pattern, which can be interpreted as a clinical match of the simulation. The results of this study show the validity of biomechanical investigations, which may serve as a method to better understand maxillofacial fracture patterns. These results will be used for the optimization of fracture therapy or trauma prevention in the future.

An analysis of studies on piezoelectric surgery in the oral and craniomaxillofacial region with regard to human subject protection and financial conflicts.

This retrospective, observational study investigated whether published studies on the use of piezoelectric surgery (PS) in the oral and craniomaxillofacial region fulfilled the requirements of the International Committee of Medical Journal Editors (ICMJE) and the Declaration of Helsinki (DoH) with respect to human subject protections (HSP) and disclosure of financial conflicts (FC). A Medline/PUBMED search was performed in April 2008 to identify all clinical studies on PS, published in English, French and German. Disclosure of HSP (obtaining ethical approval and subjects' informed consent) and FC mentioned in the retrieved articles were analysed. 29 clinical articles were identified in 18 journals, of which 14 journals (78%) required the disclosure of both HSP and FC. Ethical approval was documented in two studies (7%); patient consent was reported in four publications (14%). Four articles disclosed no FC. 21 reports (72%) mentioned neither HSP nor FC. The relationships between funding source and study outcomes could not be identified. Most studies on the use of PS hardly adhered to the regulations recommended by the ICMJE and DoH, and do not mention HSP and FC, indicating the study results with a high degree of suspicion. It is recommended that oral and craniomaxillofacial surgery journals adhere strictly to these regulations because they carry a heavy responsibility regarding the scientific integrity of publications in this specialty.

Reporting of ethical protection in recent oral and maxillofacial surgery research involving human subjects.

This retrospective observational study investigated the frequency of reporting ethical approval and informed consent in recently published oral and maxillofacial surgery (OMS) research involving human subjects. All research involving human subjects published in the International Journal of Oral and Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, British Journal of Oral and Maxillofacial Surgery, and Journal of Cranio-Maxillofacial Surgery during January to June 2005-2007 were analysed for disclosure of ethical approval by a local ethical committee and obtaining informed consent from the subjects. 534 articles were identified; ethical approval was documented in 118 (22%) and individual patient consent in 135 (25%). 355 reports (67%) did not include a statement on ethical approval or informed consent and only 74 reports (14%) disclosed statements of both. Ethical documentation in retrospective and observational studies was scant; 12% of randomised controlled trials and 38% of non-random trials did not report both of ethical protections. Most recent OMS publications involving humans failed to mention ethical review or subjects' consent. Authors must adhere to the international research ethics guidelines and journal instructions, while editors should play a gatekeeper role to protect research participants, uphold scientific integrity and maintain public trust in the experimental process and OMS profession.

Management of osteoradionecrosis of the jaws: an analysis of evidence.

AIM: To review and discuss the management of jaw bone osteoradionecrosis (JORN) based on levels of evidence. METHODS: The Medline/PUBMED and Cochrane search was performed to identify all studies on the management of JORN, published in English, French, and German during January 1975-October 2007. Only clinical researches were identified and classified into four levels of evidence before being examined. All references of the retrieved articles were analysed. FINDINGS: Seventy three articles and their additional 45 citations were evaluated. Most of the eligible literature provided observational evidence. Hyperbaric oxygen therapy (HBOT) is an adjunct; however, its clinical usefulness remains controversial. A conservative approach should be limited to early-onset JORN, while radical surgery is indicated for an advanced or refractory lesion. Free tissue transfer is the reconstruction of choice for large defects without the need of HBOT. Some new technologies have also been studied, including ultrasound, biological molecules, distraction osteogenesis and antioxidant agents. CONCLUSIONS: Most of the reports on the treatment of JORN offer weak evidence. Current information seems insufficient for establishing the definite treatment guideline; thus, well-designed studies with long-term clinical data are encouraged.

[Nasal dermoid sinus cyst: accidental coincidence or syndrome association?]. / Nasendermoide bei Peters-Plus-Syndrom: Zufall oder Syndromexpression?

BACKGROUND: Peters anomaly is a rare congenital glaucoma disease. The Peters' plus syndrome is characterized by distinct malformations. As some of the common craniofacial malformations like cleft lip and palate are frequent in Peters' plus syndrome, no nasal dermoid sinus cysts has been reported so far. Nasal dermoid sinus cysts usually present in isolation, although associations to other anomalies or syndromes are possible. The occurrence of such an anomaly may be either accidental, or present a syndrome association. PATIENTS AND METHOD: One patient with an unilateral cleft lip and Peters' plus syndrome had undergone removal of nasal dermoid sinus cyst previously and was referred for management of recurrent disease. Complete surgical removal and plastic reconstruction was performed. RESULTS: Concerning the common (lateral) cleft lip nasal deformity with no midline nasal masses, there are reasons for the assumption that a coincidence of both anomalies might be accidental. Especially in Peters' plus syndrome no occurrence of nasal dermoids has thus far been documented. However, the embryological pathway of the frontonasal region differs from lip and palate development in time and location: So unique formation of both lesions seems inconsistent. Complete surgical removal and plastic reconstruction simultaneously or in a second step are recommended. CONCLUSION: As two cases of arhinia and Peters anomaly have been described in 1978, midline nasal masses might be a possible appearance of Peters' plus syndrome.

Maturation of capillary-like structures in a tube-like construct in perfusion and rotation culture.

In an effort to engineer capillary-like networks in vitro, different cultivation methods were compared. Five small-diameter tube-like constructs ('vessel equivalents') were fabricated from porcine gelatin scaffolds and seeded with human adipose tissue stromal cells and umbilical vein endothelial cells. After initial growth, the vessel equivalents were divided. One segment was exposed to pulsatile perfusion and the other was kept in rotating culture. Specimens harvested at the start of the experiments and after 16 days of rotation or perfusion were compared histomorphometrically with respect to capillary-like network formation in the vessel wall. Most capillary-like structures were found in the luminal portion of perfused vessel equivalents. Maturation of these capillary-like structures ascertained by recruitment of alpha-actin-positive cells also reached the highest degree in the luminal portion of perfused specimens. Perfused specimens showed significantly less apoptosis. Pulsatile perfusion promotes the development and maturation of a capillary-like network in this in-vitro approach.

[Nasal dermoid and sinus cysts in patients with cleft malformations]. / Nasenfisteln und -zysten bei Patienten mit Lippen-Kiefer-Gaumen-Spalten.

BACKGROUND: Nasal dermoid sinus cysts are uncommon congenital lesions. They are usually isolated occurrences and are not associated with syndromes or additional malformations. The coincidence of both, cleft malformations and nasal dermoid sinus cysts, has seldom been reported. CASE REPORTS: Within the last 2 years two patients with reconstructed cleft lip and palate and additional nasal dermoid sinus cysts underwent surgical removal. One patient with bilateral complete cleft lip exhibited a fistula from the medial third of the nasal dorsum up to the glabella. Another patient with unilateral cleft lip and Peters' plus syndrome had undergone removal of a nasal dermoid sinus cyst 12 years ago and was referred for management of recurrent disease. DISCUSSION: Concerning the common cleft-dependent nose malformations with no midline nasal masses, there are reasons for the assumption that a coincidence of both anomalies might be accidental. Especially in Peters' plus syndrome no frequent occurrence of nasal dermoids has thus far been documented. However, the proximity and temporal closeness of an embryological pathway of the frontonasal region and lip development could also argue for a unique formation of both lesions. Complete surgical removal and plastic reconstruction simultaneously or in a second step are recommended.

[Restoration of lid function in peripheral facial palsy by implanting gold weights]. / Rehabilitation der Lidfunktion bei peripherer Fazialisparese mit Goldgewichtimplantaten.

BACKGROUND: Lagophthalmos is a common functional and aesthetic problem in patients with facial palsy. The implantation of a rigid gold weight is one technique to improve eyelid closure. The effectiveness of lid loading was investigated, taking into consideration complications ascribed to rigid implants. PATIENTS AND METHODS: We present 11 patients with facial palsy treated with that technique between April 2001 and October 2005. Before and after operation ophthalmological investigations were performed. The patients were questioned about their subjective satisfaction, and the remaining eye lid gap in the closed state was assessed. RESULTS: A good up to perfect lid closure could be achieved. Of the 11 patients, 9 reported being very contented with the result. Except for one case of extrusion, disturbed healing processes did not occur. We did not observe any occurrence of astigmatism as a result of the rigid lid load. All patients reduced their use of eye ointment and eye covers. We observed a visible bulging of the implant contour in 4 of 11 patients. However, not one of them felt discontented. All patients stated that they would undergo the lid loading procedure again. CONCLUSIONS: The implantation of rigid gold weights for lid loading in patients suffering from lagophthalmos due to peripheral facial palsy is considered a simple and effective treatment for improving eyelid closure. Whether or not flexible implants will lead to better results needs to be further investigated.

[Hemangiopericytoma (extrapleural solitary fibrous tumour). Exemplified and discussed on the basis of two cases]. / Hämangioperizytom (extrapleuraler solitärer fibröser Tumor). Dargestellt und diskutiert anhand zweier Patientenbeispiele.

BACKGROUND: Hemangiopericytoma was first mentioned in 1942. It is a very uncommon potentially malignant vascular tumour which can occur at every site of the body. According to the WHO, most of the tumours formerly diagnosed as hemangiopericytomas are considered to be extrapleural solitary fibrous tumours. The diagnosis of "hemangiopericytoma" is now only determined if a constant histological picture of hemangiopericytoma is present. The tumour can lead to lymphogenous or hematogenous metastasis. The major location of occurrence is the cutis and subcutis. It originates from the pericytes of the vascular wall. This is reflected in its vascular character and therefore the hemangiopericytoma might clinically be mistaken for a hemangioma. CASE REPORTS: Patient 1: 60 years, female; diagnosis: malignant suboccipital hemangiopericytoma; size: 4.9 x 4.5 x 4.2 cm; pT1bNXMX L0 V0 Pn0; stage IA; grading G1; R0.Patient 2: 38 years, male; diagnosis: benign hemangiopericytoma infraorbital left; size 1.5 x 1.5 x 1.5 cm. DISCUSSION: Most often the hemangiopericytoma becomes clinically conspicuous as a slowly growing, painless swelling. The consistency ranges from soft to dense, and the color is greyish-blue. The slow and painless growth carries the danger of a clinically wrong diagnosis and thus delayed therapy. The histological diagnosis of hemangiopericytoma is determined by biopsy. Besides histology, MRI and angiography are methods that can be employed to diagnose hemangiopericytoma. The therapy of choice is the complete tumour-resection with a safety margin of 1 cm. In the case of an aggressive growth pattern, adjuvant postoperative radiotherapy is recommended. Until now there has been no documented specific therapy concept for managing incomplete resection and the occurrence of metastasis. There are reports about chemo- and radiotherapy either on their own or combined which evidence differing degrees of success. Lifelong monitoring is necessary because recrudescences and metastases can occur even decades later.

[Noninvasive brush biopsy as an innovative tool for early detection of oral carcinomas]. / Nichtinvasive Bürstenbiopsie als innovative Methode in der Früherkennung des Mundhöhlenkarzinoms.

PURPOSE: The aim of this prospective study was to investigate the diagnostic accuracy of DNA image cytometry in combination with non-invasive brush biopsies taken from suspicious oral lesions. MATERIAL AND METHODS: Cytological diagnoses obtained from 1328 exfoliative smears of 332 different lesions were compared with histology and/or clinical follow-ups of the respective patients. Additionally, nuclear DNA contents were measured after Feulgen restaining using a TV image analysis system. DNA aneuploidy was assumed if abnormal DNA stemlines or cells with DNA content greater than 9c were observed. RESULTS; The sensitivity of our cytological diagnosis in addition to DNA image cytometry on oral smears for the detection of cancer cells was 97.8%, specificity 100%, positive predictive value 100%, and negative predictive value 98.1%. CONCLUSION: The application of DNA image cytometry with DNA aneuploidy as a marker for neoplastic transformation in oral smears secures cytologic diagnosis of carcinomas. Smears from brushings of all visible oral lesions are an easily practicable, cheap, noninvasive, painless, and safe screening method for detection of oral precancerous lesions and squamous cell carcinoma in all stages. We conclude that DNA image cytometry is a very sensitive and highly specific, objective, and reproducible adjuvant tool for identification of neoplastic cells in oral smears.

[Intraoral application of vacuum-assisted closure in the treatment of an extended mandibular keratocyst]. / Intraorale Vakuumtherapie zur Behandlung einer ausgedehnten Zyste des Unterkieferknochens.

In extended cysts of the jaw bone particular demands are made in terms of wound closure, especially if an intraoral surgical approach is chosen. A tight closure is even more important if the bony defect has been filled with an alloplastic material or autologous cancellous bone. In our case a keratocyst of the left mandibular angle and ascending ramus was treated. After enucleation of the cyst and grafting with autologous cancellous bone the graft was lost following a wound breakdown. Subsequently a system was developed to apply intraoral V.A.C.-therapy. This led to a safe separation of the cystic defect and the oral cavity and a conditioning of the wound ground. A grafting with an alloplastic material was carried out successfully. With this method the length of treatment could be reduced by several months compared to a conventional therapy with an obturator.

[Functional and aesthetic outcome of nasal surgery in cleft lip palate patients]. / Funktionelle und ästhetische Ergebnisse von Nasenkorrekturen bei Patienten mit Lippen-Kiefer-Gaumen-Spalten.

Between June 1996 and November 2000 60 patients suffering from severe nasal dysplasia due to cleft lip and palate (CLP) underwent corrective nasal surgery. Diagnoses included 37 cases of unilateral CLP and 23 cases of bilateral CLP. Age ranged from 7 to 50 years. To assess functional outcome three different methods were used pre- and postoperatively with and without nasal decongestion: active anterior rhinomanometry, rhinoresistometry, and acoustic rhinometry. For the measurement of esthetic changes frontal, lateral, and caudal photographs were analyzed. Compared to a non-cleft population esthetic and functional impairment was evident preoperatively. Postoperatively a statistically significant improvement in nasal projection and configuration was seen. Concerning nasal respiration an improvement in nasal flow and hydraulic diameter was noted in the unilateral CLP group only, whereas a statistically nonsignificant average deterioration was found in the bilateral CLP group. No correlation existed between external nasal form or the change in nasal appearance and nasal function. Whereas the esthetic outcome of nasal surgery is covered by way of photo-analysis in many centers, a distinct lack of measuring the effects on nasal function can be stated. Without using objective methods, however, no data for improving surgical procedures and for internal quality control are at hand.

[Distraction osteogenesis in the treatment of severe midfacial hypoplasia]. / Therapie ausgeprägter Mittelgesichtsrüklagen mit Hilfe der Distraktionsosteogenese.

PATIENTS: Between May 1998 and May 2002, 38 patients suffering from severe midfacial retrusion and atrophy were treated by way of midfacial distraction osteogenesis. Diagnoses included cleft lip and palate (32 patients) and one case of Crouzon's disease. Ages ranged from 6-65 years. A total of 28 patients presented a velopharyngeal flap and nine patients were almost or fully edentulous. Using an extraoral halo device, distraction was performed after a subtotal Le Fort-I/II/III or modified quadrangular osteotomy. RESULTS: Distraction ranged from 9 to 31 mm (17 mm average). Following the primary operation, seven patients underwent a second intervention due to problems with the procedure or the device. Two patients needed a secondary Le Fort-I-osteotomy. With respect to velopharyngeal insufficiency, 21% showed a deterioration and 8% an improvement. Postoperatively, a decrease of 15-20% in the attained sagittal advancement was seen during the first 6 months. This was attributed to relapses and postoperative orthodontics. Thereafter skeletal stability was maintained. CONCLUSION: Distraction osteogenesis of the midface can be the method of choice in severe midfacial retrusion. Due to the difficult patient situation and the technical intricacies a higher complication rate has to be accepted than for conventional dysgnathia operations.